Versatility of Vein Grafts in Hand Neurovascular Reconstruction – Clinical Cases and Literature Review

Injuries to the upper limb may determine unexpected simple or complex soft tissue defects, due to different types of underlying injury mechanism, clean cut/stabs, crushing, torsion, avulsion or mixed types, which pose a challenge for the reconstructive surgeon. Ideally, all arterial, venous and nervous lesions, in the distal upper limb should be repaired in an end-to-end technique, outside of injury zones, with healthy ends, in a tension free manner. However, situations arise where, either a tension-free repair is not possible, or a considerable defect is met, often representing a challenge to the surgeon. Therefore, a timely decision is imposed in order to find the most favorable approach to restore limb or segment perfusion, ensuring efficient venous return, as well as providing a sensate repair. Usage of vein grafts represents an essential tool comprised in the reconstructive surgeon’s armamentarium, with high versatility in nerve, arterial and venous reconstruction. Not only does it provide an ideal solution, with high adaptability to each case, but it also may enhance short- and long-term outcome, offering an optimal reconstructive option in any upper limb trauma situation, regardless of etiology. We aim to describe our therapeutic strategies in a series of challenging trauma cases involving digital structures from the upper limb. Interposed vein grafts were used to re-stablish sensate function in a patient with a collateral digital nerve defect, but also to bridge vital digit arterial defect in a torsion-avulsion thumb amputation, as well as re-establishing venous flow in patients with Urbaniak II finger degloving injury.

LICAP Versus TDAP for Reconstruction of Partial Breast Defects

BackgroundPerforator flaps are the latest development in reconstructive surgery. Pedicled chest wall perforator flaps can be utilized in many cases of partial breast reconstruction. This research compares the outcome and technique of Thoracodorsal Artery Perforator Flap (TDAP) and the Lateral Intercostal Artery Perforator Flap (LICAP) in reconstruction of partial breast defects.MethodsPatient records were reviewed for the time period between 2011-2019 at the breast unit of the National Cancer Institute of Cairo University. Eighty three patients were accessible for the study. (46 cases of TDAP flap and 37 cases of LICAP flap). Relevant clinical data were extracted from patients’ records. A special visit was organized for all 83 patients ,where a digital photograph was taken in an antro-posterior view. The photographs were later processed via BCCT.core software to obtain an objective cosmetic outcome assessment.ResultsComplication rates and cosmetic outcome were comparable for both techniques. TDAP flap flap proved to require more tedious dissection and preoperative Doppler mapping to localize perforator vessels. On the other hand LICAP was technically easier with more consistent perforators.ConclusionPedicled chest wall perforator flaps constitute an excellent reconstructive option in partial breast defects. They have replaced musculocutaneous flaps to a large extent.

Sternal defect reconstruction using a double-barrel vascularized free fibula flap: a case report

Total and subtotal sternectomy oncological defects can result in large deficits in the chest wall, disrupting the biomechanics of respiration. Reviewing the current literature involving respiratory function and rib motion after sternectomy, autologous rigid reconstruction was determined to provide the optimal reconstructive option. We describe a novel technique for sternal defect reconstruction utilizing a double-barrel, longitudinally oriented, vascularized free fibula flap associated with rib titanium plates fixation. Our reconstructive approach was able to deliver a physiological reconstruction, providing rigid support and protection while allowing articulation with adjacent ribs and preservation of chest wall mechanics.

APPLICATION MAXILLOFACIAL MICROSURGERY AT HANOI NATIONAL HOSPITAL OF ODONTO-STOMATOLOGY

Background: Microsurgery is a highly complex technique that requires specialized equipment and steady surgical techniques. This is a retrospective review of the development progress of microsurgical techniques at Hanoi National Hospital of Odonto-Stomatology (NHOS) during the past 12 years. Methods: Retrospective study assessing the training and developing process of microsurgical techniques at NHOS in 12 years. Results: NHOS has performed 665 microsurgical flaps reconstructions after surgical removal of large tumors in maxillomandibular area. 441 fibular free flaps were harvested for mandibular reconstructions after resections of ameloblastoma and osteofibroma. 4 fibular flaps were used for maxillary reconstructions. 119 osteocutaneous fibular free flaps were harvested for mandibular reconstructions in oral cancer surgeries. 83 lateral arm flaps and 13 anterolateral thigh flaps reconstructions were performed following cancer ablations. 5 patients underwent reconstruction after cancer resection with 2 fibular free flaps and anterolateral thigh flaps. Success rate is 654/665 (98.35%). Conclusion: The implementation of microsurgery technique at NHOS has been carried out for only 12 years but rapid and significant progress has been made. Free flap reconstruction is a flexible reconstructive option to restore essential functions and aesthetics of the facial area and to improve the patient's quality of life.

Consistent Value of Two-Stage Pedicle Flaps in the Age of Microsurgical Maxillofacial Reconstruction

Introduction Up to the second half of the twentieth century, pedicled flaps marked the gold standard in reconstructive surgery. Followed by the introduction of microsurgical techniques, these flaps were increasingly abandoned. We conducted a retrospective study to determine the value of two-stage pedicle flaps in modern maxillofacial reconstruction. Material & Methods A chart review from October 2017 to November 2020 was performed to identify patients who were treated by a two-stage pedicle flap in our Department of Oral and Maxillofacial Surgery. Results A total of 31 patients, 17 female and 14 males received 36 two-stage pedicle flaps. All patients were in noticeably impaired health condition with a majority of ASA-score 3. The defect location mainly contained extraoral resections (58.3%). A variety of flaps were harvested consisting of buccal flaps, Abbe flaps, forehead flaps, deltopectoral flaps, nasolabial flaps, and a tubed flap. Discussion The study outlines two indications for the use of two-stage pedicle flaps. Firstly, as a back-up strategy in heavily pre-treated wound beds and secondly in an almost contrarily indication as a first-choice reconstructive option of the facial skin in esthetic demanding cases. Conclusion The timesaving and straight forward surgical approach as well as their low postsurgical complications and strong long-time success rates secure the two-stage pedicle flap a justified niche role in times of microsurgical maxillofacial reconstruction.

Treatment Recommendations for Suspected Scapholunate Ligament Pathology

Background The diagnosis and treatment of scapholunate interosseous ligament (SLIL) pathology is debated and notably variable. This study assessed the influence of diagnostic arthroscopy on treatment recommendations and the interobserver reliability of the arthroscopic classification of SLIL pathology. Methods The influence of diagnostic arthroscopy on treatment recommendations and the reliability of the arthroscopic classification of SLIL pathology were tested in a survey-based experiment. Seventy-seven surgeons evaluated 16 scenarios of people with wrist pain with variation in symptoms, scaphoid shift, time of symptom onset, and MRI appearance of the SLIL. Participants were randomized to view or not to view diagnostic wrist arthroscopy. Factors associated with recommendation for repair, capsulodesis, or tenodesis were analyzed. Results Viewing arthroscopic videos was associated with both offering surgery and a more reconstructive option. Other factors independently associated with recommendation for surgery included greater pain intensity and activity intolerance, women surgeons, an asymmetric scaphoid shift, and a recent onset of symptoms. The interobserver reliability of SLIL classification was slight. Conclusions Diagnostic arthroscopy leads to more surgery, and more invasive surgery, in spite of unreliable assessment of pathology. Clinical Relevance This points to the need to measure the potential benefits and harms of diagnostic wrist arthroscopy among people with wrist pain and no clear diagnosis on interview, examination, and radiographs. Level of Evidence Not applicable.

Comparative outcome analysis of osseointegrated reconstruction and replantation for digital amputations

The long-term outcomes of osseointegration for digital amputations are not well established, and it is not known whether osseointegration can achieve similar function and patient satisfaction to conventional surgical options such as replantation and microsurgical toe transfer. We compared the long-term outcomes after digital osseointegration and replantation. Six patients treated by osseointegration and seven patients treated by replantation were included, with median follow-ups of 8 years and 4.6 years, respectively. Outcomes were assessed using the Michigan Hand Outcomes Questionnaire, grip and pinch strength, range of motion, two-point discrimination, Semmes-Weinstein tests, Jebsen-Taylor Hand Function Test and clinical photography. Osseointegration was associated with poorer sensibility and range of motion than replantation; no other differences reached statistical significance. Long-term osseointegration is a safe and effective reconstructive option that can deliver excellent outcomes in appropriately selected patients. Level of evidence: IV

Abdominal-based adipocutaneous advancement flap for reconstructing inguinal defects with contraindications to standard reconstructive approaches: a simple and safe salvage reconstructive option

Background Groin wounds occurring after vascular surgical site infection, oncologic resection, or occasionally orthopedic surgery and trauma may represent a surgical challenge. Reconstruction of these defects by the usual workhorse flaps may be contraindicated following previous surgery and in patients with lower limb lymphedema or extreme morbidity.Methods This study included 15 consecutive patients presenting with inguinal wounds after vascular or general surgery that required debridement and soft tissue coverage. All cases had absolute or relative contraindications to conventional reconstructive techniques, including a compromised deep femoral artery network, limb lymphedema, scarring of potential flap harvesting sites, or poor overall condition. Abdominal adipocutaneous excess enabled the performance of adipocutaneous advancement flaps in an abdominoplasty-like fashion. Immediate and long-term outcomes were analyzed.Results Soft tissue coverage was effective in all cases. Two patients required re-intervention due to flap-related complications (venous congestion and partial flap necrosis). All patients fully recovered over a mean±standard deviation follow-up of 2.4±1.5 years.Conclusions Abdominal flaps can be an effective and simple alternative technique for inguinal coverage with reproducible outcomes. In our experience, the main indications are a compromised deep femoral artery network and poor thigh tissue quality. Relative contraindications, such as previous open abdominal surgery, should be considered.

Preemptive Utilization of Anterior Belly of the Digastric Muscle Flaps in Transoral Robotic Radical Tonsillectomy

Objective To demonstrate the use of an anterior belly of the digastric muscle flap (ABDMF) during transoral robotic radical tonsillectomy (TORRT) with concomitant neck dissection with the intent of preventing the formation of postoperative pharyngocutaneous fistulas. Study Design Retrospective study. Setting Single academic tertiary care center. Methods In this study, all patients were included who underwent TORRT plus limited pharyngectomy with concomitant neck dissection and ABDMF for the treatment of oropharyngeal squamous cell carcinoma between September 2012 and September 2020. The rate of fistula formation was assessed in patients with preemptive utilization of ABDMF. Results A total of 43 patients underwent TORRT with neck dissection and ABDMF. No patients developed a fistula in the postoperative period or associated morbidity with the use of this flap. Conclusion Preemptive use of ABDMF in TORRT with concomitant neck dissection represents a reconstructive option that may help prevent the formation of pharyngocutaneous fistula by reinforcing the posteroinferior boundary of the parapharyngeal space.

Single-Stage Peninsula-Shaped Lateral Tongue Flap Reconstruction for Buccal Defects in Two Patients: Revisiting a Simple and Safe Reconstructive Option

Intraoral defects are increasingly reconstructed using free flaps. However, certain situations may render free flap reconstruction difficult. This study presents two cases with underlying comorbidities that underwent reconstruction of buccal defects involving the retromolar trigone (RMT), using a single-stage peninsula-shaped lateral tongue flap (pLTF). A 58-year-old woman and a 75-year-old man were diagnosed with left buccal squamous cell carcinoma and right buccal adenoid cystic carcinoma, respectively. The buccal defects extending to the RMT area were detected and covered with an ipsilateral posteriorly based pLTF after wide excision of the lesion. All flaps survived without any postoperative complications. Moreover, no tumor recurrences or functional problems were observed during the final follow-up. A single-stage pLTF is believed to represent a good alternative to free flaps in buccal and RMT defects.